HIV/AIDS: why prevention campaigns do (not) occur? Gani Aldashev CRED, University of Namur

1. HIV/AIDS: why prevention campaigns do (not) occur? Gani Aldashev CRED, University of Namur (based on research joint with Jean-Marie Baland, CRED)

2. Motivation • Puzzle 1: Why so little policy response to HIV/AIDS in the developing world, even in the countries with very high prevalence?

3. Motivation

4. Motivation • Puzzle 2: reversal in downward incidence and prevalence trends in the countries that have initially taken active stance against the disease

5. Motivation

6. Success stories • Uganda 1986: Museveni takes active stance on public awareness program • “As mortality rises people began to respond, but the hope is that there is a way to short circuit this process. Uganda suggests that the only way to do this is through leadership creating the environment in which society can discuss these issues” (Whiteside et al. 2004) • Thailand 1980s: no debate because of negative effects on tourism, in 1991, the prevention and control of HIV/AIDS became the top priority for the government, with massive public information program. • Similar in Brazil, Senegal (with support of religious leaders!), and Philippines.

7. Failure stories • South Africa –Mbeki initially recognized the importance of the epidemic, and later on reverted to complete denial of the problem. In the elections in 2004, opposition parties campaigned on platforms proposing “free ARVs,” yet the ANC still gathered 70% of the vote. (Bor 2007) • Kenya 1996 – Demonstrations orchestrated by religious leaders. President Arap Moi called to refrain from sex as the main prevention activity, and denied the importance of more active measures such as subsidizing condoms: “As president, I am shy that I am spending millions of shillings importing those things”

8. Important aspects • Awareness and Effectiveness of Government Action • “Southern Africans simply do not list HIV/AIDS as a political priority for their governments … it could be that people see the responsibility for HIV/AIDS to lie with individuals and communities rather than governments, perhaps because they do not believe that governments have the ability to deliver in this area” (Whiteside et al. 2004) • “The failure of elected leaders to respond to AIDS may reflect a rational response to the demands of their constituents. Africans consistently rank HIV/AIDS low among their political priorities, preferring government action on unemployment, the economy, poverty, water, and crime” (Bor 2007)

9. Important aspects • The Role of Discussions and Social Networks in creating political support for public action • 90% of Ugandans discussed AIDS with others compared to less than 35% of South Africans • Stoneburner and Low-Beer (Science, 2004) show that the success in Uganda is strongly associated with communication about AIDS through social networks

10. Policy and awareness • Policy action affects the extent of public awareness and social network discussions …but awareness in turn provides support for public action • It is important to consider both channels • From public awareness to policy (via voting / other political mechanisms of representation) • From policy to awareness (directly and via intergenerational transmission of knowledge)

11. The model: awareness • We have built a simple model in which both the disease and awareness about prevention get transmitted across generations: • Individuals are born healthy, but some of them get the disease from the older generation via sexual contact (« sugar daddies » in Kenya) • Individuals are bborn unaware, but some of them get the information about prevention from the generation of their parents

12. The model: awareness • 3 types of individuals: • Aware: provide political support for massive prevention campaigns • Unaware: consider such campaigns ineffective (« positive cost, no benefit »), thus are against • Conservative: regardless of the cost-benefit calculation, are ideologically opposed to campaigns • The campaigns are conducted only if type-1 individuals are a majority: Naware > Nunaware + Nconserv

13. Stationary equilibria • Two key variables in the model evolve over time: • Rate of disease prevalence (alpha) • Rate of awareness among the voting population (q) • Stationary equilibrium: when these variables settle at some constant value

14. Stationary equilibria

15. Vicious circle • First stable equilibrium: • Low awareness, no campaigns, high prevalence • « Vicious circle »: • Relatively few people are aware about the prevention possibilities … • … therefore, not enough political support for massive prevention campaigns … • … little diffusion of information in social networks • Consequences: • High prevalence of the disease • Few young people who are aware  not enough political support also in the future! • This explains puzzle 1: countries like South Africa, Kenya, Nigeria, etc., are « caught » in the vicious circle

16. Virtuous circle • Second stable equilibrium: • High awareness, massive campaigns, low prevalence • « Virtuous circle »: • A large number of people is aware about the prevention possibilities … • … therefore, sufficient political support for massive prevention campaigns … • … diffusion of information in social networks increases • Consequences: • Low prevalence of the disease • Many young people who are aware  enough political support to sustain the policy also in the future

17. Short run dynamics

18. Short run dynamics • The ‘good’ equilibrium is fragile: • If the disease prevalence falls (temporarily) below a certain threshold, the aware citizens give political support for a smaller-scale prevention campaign • This induces a number of aware in the next generation which is too small to constitute a majority … • … and in the future, the policy gets eliminated! • This explains Puzzle 2: • “Increase in HIV prevalence in Uganda is being fueled by complacency, as well as a decreased intensity of prevention programs, funding, and political commitment” (Munaabi 2006)

19. Lessons • How did countries like Uganda, Brazil, and Thailand become « success stories »? How did they manage to get out of the vicious circle? • Role of leadership • Abdou Diouf (Senegal) • Museveni (Uganda) • What to do when leaders do not take active position against the disease? • Role for NGOs: • Large concerted campaigns. Should be large enough to push the situation out of « vicious circle » • Combatting complacency to preserve the « virtuous circle » (Uganda, Thailand)